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Objective: The epidemiological profile of congenital anomalies of the upper limbs (CAULs) is of major relevance to monitoring and planning. A study of this profile may reveal if there is prevalence of some specific type of malformation in comparison to a more comprehensive epidemiological sample. The Latin American Collaborative Study of Congenital Malformations (ECLAMC) has an extensive database, providing an excellent source of comparison. This study aims to evaluate the epidemiological profile of CAULs at the hand surgery department of the Hospital Federal da Lagoa (HFL) in Brazil, and compare it to the ECLAMC data. Methods: We conducted a retrospective analysis of patients who underwent treatment at the pediatric outpatient hand surgery clinic. The sample universe consisted of 126 patients (4 of these patients presented with 2 simultaneous anomalies), totaling 130 malformations. Results: The results demonstrated that the comparable pathologies have significantly similar incidence rates. It is worth noting the polydactylies (pre- and post-axial), where the percentile of incidence in the ECLAMC was higher. Conclusion: This study showed that the epidemiological profile of patients who underwent treatment at this hospital was equivalent to that found in the ECLAMC database. Level of evidence III, Retrospective epidemiological study. RESUMO Objetivo: O perfil epidemiológico das anomalias congênitas dos membros superiores (ACMS) é de suma relevância para monitoramento e planejamento. Um estudo nesse sentido pode revelar se há prevalência de algum tipo específico de malformação em comparação com amostra epidemiológica mais abrangente. O Estudo Colaborativo Latino Americano de Malformação Congênita (ECLAMC) tem uma extensa base de dados, que serve como excelente fonte de comparação. Este estudo tem por escopo avaliar o levantamento da casuística das ACMS no serviço de cirurgia da mão do Hospital Federal da Lagoa (HFL) e compará-la aos dados do ECLAMC. Métodos: Foi realizada uma análise retrospectiva dos pacientes atendidos no ambulatório infantil de cirurgia da mão. O universo amostral foi de 126 pacientes (sendo que 4 pacientes apresentavam 2 anomalias simultaneamente), totalizando 130 malformações. Resultados: Demonstrou-se que as patologias que puderam ser comparadas têm percentuais de incidência significativamente semelhantes. Cabe ressalvar as polidactilias (pré e pós-axiais), em que o percentil de incidência no ECLAMC foi maior. Conclusão: Este estudo evidenciou que o perfil epidemiológico dos pacientes atendidos neste hospital foi equivalente ao encontrado na base de dados do ECLAMC. Nível de evidência III, Estudo epidemiológico retrospectivo.

Surgical site infection (SSI) is recognized as a focus area by the Centers for Medicare and Medicaid Services, the Joint Commission, the Institute for Healthcare Improvement, and the Institute of Medicine. An estimated 47% to 84% of SSIs present after discharge from the hospital or ambulatory care facility and, as a result, go undetected by standard SSI surveillance programs. Evidence-based processes and practices that are known to reduce the incidence of SSIs tend to be underused in routine practice. This article describes a multistakeholder process used to develop an educational initiative to raise awareness of best practices to reduce SSIs. The goal was to create a patient-centric educational initiative that involved an active partnership among all stakeholders-medical professional organizations, hospitals/health systems, health insurers, employers and other purchasers, and consumers/patients-to provide the climate necessary to create and sustain a culture of safety.

Objectives To describe and evaluate a novel practice setting for a pharmacist within an occupational health clinic. Setting Ambulatory care facility. Practice Description Implementation and evaluation of a new practice site embedding a clinical pharmacist into the workplace to provide ambulatory care services, such as comprehensive medication management, disease state management, and immunizations to a broad diversity of patients. Practice Innovation A clinical pharmacist provides pharmacy services as part of a collaborative occupational health clinic at a large, self-insured company. The pharmacy services are open to employees and family members with any chronic disease states, elevated biometric results, or medication questions, with the goal of improving patient care on a consistent basis. During visits, the pharmacist works to identify and resolve drug-related problems by educating the patient or reaching out to the patient’s health care provider and to develop strategies with the patient to achieve desired health care outcomes. The pharmacist assists with patient outreach events and immunizations during the flu clinic. Evaluation Identification of drug-related problems, resolution status, patient satisfaction via survey results, immunizations provided. Results In 4.3 years of operation, the pharmacist conducted 604 visits with 172 patients. During these visits, the pharmacist identified 611 drug-related problems, of which 49.4% have been confirmed as resolved. All patients who completed the patient satisfaction survey said that they would recommend the pharmacy services to others. For the past 3 years, the pharmacist and pharmacy students immunized approximately 1000 patients each year during the company flu clinic. Conclusion An occupational health clinic is a unique and convenient location for a pharmacist to provide ambulatory care services to employees and family members, as long as methods to identify patients and appropriate sources of referral exist. The pharmacist was able to help patients resolve approximately 50% of identified drug-related problems, and patients were highly satisfied with services provided.

Background Unsedated colonoscopy is not required by the Accreditation Council of Graduate Medical Education in the curriculum of GI trainees. Objective We describe our pilot experience with trainee participation in unsedated colonoscopy. Design A retrospective review of a performance improvement program to provide access to colonoscopy. Setting A Veteran's Affair ambulatory care facility that discontinued sedated colonoscopy because of a nursing shortage. Patients A total of 145 of 483 patients who chose unsedated colonoscopy after both sedated and unsedated options were discussed. Interventions GI fellows performed unsedated colonoscopy under the supervision of the attending physician. Main Outcome Measurements Cecal intubation rate, patient assessment of the reasons for the choice, the unsedated experience, willingness to have another colonoscopy, and the rate of return for unsedated colonoscopy among eligible patients. Results Cecal intubation was achieved in 112 of 145 patients. The adjusted success rate (excluding inadequate bowel preparation and an obstructing lesion) was 81%. The most frequently acknowledged reason for the choice was the ability to communicate with the colonoscopist. Eighty-six patients reported a good experience and were likely to accept another unsedated colonoscopy. To date, all 8 patients eligible for 3-year follow-up successfully completed another unsedated examination. Limitation An uncontrolled, nonrandomized review in predominantly male older veterans. Conclusions An unsedated colonoscopy might be acceptable to some populations, particularly when communication with clinicians and procedural convenience are highly valued. Involvement of trainees is feasible. Randomized controlled comparisons of sedated and unsedated options in terms of safety (eg, sedation and procedure-related complications) and cost in settings with and without a nursing shortage deserve to be considered.

Public health activities to identify and monitor persons at risk for Ebola virus disease in the United States include directing persons at risk to assessment facilities that are prepared to safely evaluate for Ebola virus disease. Although it is unlikely that a person with Ebola virus disease will unexpectedly present to a nonemergency ambulatory care facility, the Centers for Disease Control and Prevention have provided guidance for this setting that can be summarized as identify, isolate, and inform.

Advances in medicine have improved the delivery of health care, making it more technologically superior than ever and, at the same time, more complex. Nowhere is this more evident than in the surgical arena. Plastic surgeons are able to perform procedures safely in office-based facilities that were once reserved only for hospital operating rooms or ambulatory surgery centers. Performing procedures in the office is a convenience to both the surgeon and the patient. Some groups have challenged that performing plastic surgery procedures in an office-based facility compromises patient safety. Our study was done to determine whether outcomes are adversely affected by performing plastic surgery procedures in an accredited outpatient surgical center. A retrospective review was performed on 5316 consecutive cases completed between 1995 and 2000 at Dallas Day Surgical Center, Dallas, Texas, an outpatient surgical facility. Most cases were cosmetic procedures. All cases were analyzed for any potential morbidity or mortality. Complications requiring a return to the operating room were determined, as were infection rates. Events leading to inpatient hospitalization were also included. During this 6-year period, 35 complications (0.7 percent) and no deaths were reported. Most complications were secondary to hematoma formation (77 percent). The postoperative infection rate for patients requiring a return to the operating room was 0.11 percent. Seven patients required inpatient hospitalization following their procedure secondary to arrhythmias, angina, and pulmonary emboli. Patient safety must take precedence over cost and convenience. Any monetary savings or time gained is quickly lost if safety is compromised and complications are incurred. The safety profile of the outpatient facility must meet and even exceed that of the traditional hospital-based or ambulatory care facility. After reviewing our experience over the last 6 years that indicated few complications and no deaths, we continue to support the judicious use of accredited outpatient surgical facilities by board-certified plastic surgeons in the management of plastic surgery patients.

This definitely was not the type of day that St. James Hospital CEO, Paul Ryan, was expecting. As the groundbreaking ceremonies for the Hospital s new addition were about to begin, Paul found himself facing an unsympathetic press and an angry group of protesters. Clearly, he had a crisis on his hands. BACKGROUND St. James Hospital in Parramatta (Western Sydney area of New South Wales, Australia) is a 400-bed multi-specialty community hospital providing ambulatory care, acute care, and psychiatric care services to residents living within the five suburbs of Auburn, Holroyd, Parramatta, Blacktown, and Baulkhaum Hills in the area of Western Sydney. The population of this area is multi-cultural with nearly one-third of the population born overseas and thirty percent speaking a language other than English. The area's population also differs from the population of New South Wales in other demographic characteristics. Table 1 shows some of these differences, although the data do not always allow direct comparisons. These differences have presented the management and staff of St. James Hospital with special sociocultural, financial, and communication challenges. Three years ago, the Board of Directors of St. James Hospital developed a plan to build a new ambulatory care facility to replace its inadequate facilities located within the existing hospital structure. Last year, the Hospital was awarded a Certificate of Need by the Sydney Health Facilities Planning Board to construct a new 40,000 square-foot ambulatory care building. The Certificate confirms that a new facility is in the best interests of the community; that the facility will not cause financial hardship on the community; and that the community has ample opportunity to express its views on the impact of the facility. Paul Ryan, the Hospital's chief executive officer, along with the Hospital's health planner and vicepresident of operations worked exclusively with the architect to plan the new facility, taking the plan to the Hospital's Board of Directors for ultimate approval. The plan they took to the Board proposed a twostory ambulatory care facility with an attached parking garage, extending from the west end of the existing hospital structure, which housed the current outpatient area (see Figure 1). The only drawback of the plan was that the new facility would extend across a section of George Street. The architect determined that the facility could not be built over the street and that a portion of George Street would therefore have to be purchased from the Parramatta City Council to accommodate the new facility. Twelve of the thirteen Board members enthusiastically endorsed the plan, provided that the street could be purchased for less than $250,000 from the Council. The thirteenth Board member, John Wee, noted that the proposed street was the only major artery to the predominately poor neighbourhood located just north of the hospital. He noted that the proposed plan required the local residents to drive three blocks around the proposed facility to get to the Hospital. George Street was the most convenient access street. Paul Ryan, noted that the proposal was the most efficient and cost-effective plan possible. He further noted that he was certain the neighbourhood would support any project that St. James Hospital sponsored. "What's more important," he argued, "a health care facility or a three-block detour?" John Wee commented: I agree that the proposed plan is the most efficient and cost-effective way to provide the new facility; however, I think many of the local residents are going to object to the required re routing of traffic. What other alternatives has the architect considered? Paul Ryan explained that the architect considered two other alternative plans to avoid the obstruction to George Street. One alternative was to locate the new facility six blocks from the site of St. James Hospital. …

Background: Information is vital to cancer patients. Physician-patient communication in oncology presents specific challenges. The aim of this study was to evaluate self-reported information of cancer patients in ambulatory care at a comprehensive cancer centre and examine its possible association with patients' demographic and clinical characteristics. Patients and methods: This study included adult patients with solid tumours undergoing chemotherapy at the Institute Jules Bordet's Day Hospital over a ten-day period. EORTC QLQ-C30 and QLQ-INFO25 questionnaires were administered. Demographic and clinical data were collected. Descriptive and inferential statistics were used. Results: 101 (99%) fully completed the questionnaires. They were mostly Belgian (74.3%), female (78.2%), with a mean age of 56.9 ?12.8 years. The most frequent tumour was breast cancer (58.4%). Patients were well-informed about the disease and treatments, but presented unmet information domains. The Jules Bordet patients desired more information on treatment side effects, long-term outcome, nutrition, and recurrence symptoms. Patients on clinical trials reported having received less information about their disease and less written information than patients outside clinical trials. Higher information levels were associated with higher quality of life (QoL) scores and higher patient satisfaction. Conclusion: Patients were satisfied with the information they received and this correlated with higher QoL, but they still expressed unmet information wishes. Additional studies are required to investigate the quality of the information received by patients enrolled in clinical trials. the authors; licensee ecancermedicalscience., SCOPUS: ar.j, info:eu-repo/semantics/published

Sedatives are an important and necessary management technique for some children during dental procedures. Sedation can be administered safely and efficiently by competent practitioners who have special training in the use of the technique in children and who adhere to sedation guidelines. Nonetheless, some children present with special needs, such as medically compromising conditions, or multiple carious teeth in a child who is fearful or whose family must travel a long distance for care. Sedation cannot always safely and adequately meet the needs of these children. In these cases, general anesthesia in a hospital, ambulatory care facility, or office is indicated and must be provided by an appropriately licensed and trained physician or dentist.

Objective To document and evaluate pharmacists' interventions in a setting that has complete and immediate access to patient information. Design Descriptive report evaluating self-reported interventions made by pharmacists during the conduct of routine dispensing activities. The data collection period was from February 15 to April 1, 1994. Setting Ambulatory care facility offering medical and dental care to high school residents, Native Americans, and Alaska Natives in Northwestern Oregon. Main Outcome Measures Intervention rate per 100 new prescriptions dispensed. Each intervention was evaluated with regard to the information used to initiate it, when during the dispensing process it was initiated, and the intervention type. Outside evaluators determined the clinical significance of the interventions, including potential adverse health consequences, the likelihood of their occurrence, and the level of medical care that would have been required to treat the problem. Results Of 2,535 orders screened, 104 interventions (4.1%) were collected; 71% of these occurred during chart screening. Pharmacists most often used the medication order itself (60.6%) to detect prescribing problems, followed by other records in the patient's chart (29.8%). Outside evaluators identified 47.1% of the 104 interventions as clinically significant. The most common adverse health consequence prevented was inadequate control of the patient's condition. Outside evaluators also found that the most common level of corrective care that would have been needed if the intervention had not occurred, was a scheduled physician office visit (59.2%). Conclusion This information suggests that pharmacists who have access to patient information may intervene at higher rates and that more of their interventions may be deemed clinically significant. However, larger, double-blinded, case-controlled studies are needed to definitively draw these conclusions.

This article discusses a variety of topics that need to be addressed during the design of an ambulatory care facility, particularly those areas that need to be discussed at the beginning of the project. Topics include life safety/code issues involving building classification, employee safety, and accessibility; regulatory agencies; design issues including design sources, touring comparable facilities, room mock-ups, staff evaluation/wish list, setting standards, and determining responsibility; and medical equipment including planning and current trends. The time you spend planning ahead is time well spent.

Previous outpatient services have focused on patient waiting times in-clinic, for which the Patients' Charter sets a 30 minute limit. But the Patients' Charter also puts limits on the time a patient waits for first outpatient appointment after referral A computer simulation program has been developed which can model the new referral waiting list of any ambulatory care facility. The package has been applied in a case-study clinic for the purpose of predicting the impact of various scenarios on new referral waiting time.

Background The chronic obstructive pulmonary disease (COPD) and the bronchial asthma are widespread diseases. They need long-lasting and sustainable rehabilitation. Objectives The goal of this HTA is to describe the present supply and the economic relevance of out-patient pulmonary rehabilitation in conjunction with its social aspects. A further target is to derivate options for actions in the health-care system and possible research necessities. Methods Relevant publications are identified by means of a structured search in 37 database accessed through the German Institute of Medical Documentation and Information (DIMDI). In addition a manual search of identified reference lists has been done. The present report includes German and English literature published from 2004 to 2009. The methodological quality was assessed by two independent researchers according to pre-defined quality criteria of evidence based medicine. Results Among 860 publications 31 medical studies, four economic studies and 13 ethical studies meet the inclusion criteria. The studies cover rehabilitation programmes in 19 countries. The majority of them has a high level of evidence (1A to 2C). The pulmonary rehabilitation programmes differ by the setting (in-patient, out-patient, in-home, community-based), by the length of intervention (from two weeks to 36 months), by the way and the frequency of intervention and by the duration of the follow-up treatment. Overall out-patient rehabilitation programmes achieve the same positive effects for COPD patients as in-patient programmes do. This is especially true for physical performance and health related quality of life. There are only a few studies dealing with asthma. Therefore, valid statements cannot be given. The results for cost-effectiveness are not distinct enough. Discussion Goals of pulmonary rehabilitation like prevention and adequate treatment of acute exacerbations, the minimisation of hospitalisation and the reduction of mortality are attained in out-patient as well as in in-patient pulmonary rehabilitation. Regarding the best frequency of training units per week or the duration and the content of a unit further research is needed. Final results for the ideal length of an in-patient rehabilitation are still missing. None of the studies deals with the analysis of the different treatment forms of a COPD which are frequently defined by an alteration of in-patient and out-patient treatments and participation in sports clubs or self-help groups. There are some other limitations of the studies. The results concerning self-management programmes are not distinct. (Self-) Selection leads to high drop-out rates. Many studies have only small sample sizes. Confounder and long-time effects are seldom researched, relevant economic evaluations do not exist The improvement of health related quality of life is primarily obtained by an improved disease management than by an improvement of a medical parameter. Conclusion Out-patient pulmonary rehabilitation is as effective as in-patient pulmonary rehabilitation. But there is a critical shortage of out-patient pulmonary rehabilitation supply in Germany. Domains for further research are the evaluation of models for integrated care, the length, frequency and content of training programmes, psychiatric assessments and the cost-effectiveness of out-patient pulmonary rehabilitation., GMS Health Technology Assessment; 6:Doc11; ISSN 1861-8863

Article-at-a-Glance Background Monitoring hand hygiene guideline compliance in an ambulatory environment can be challenging. For example, direct observation by independent observers is impractical because the sink and hand sanitizer dispensers are most often located inside the examination room. At Johns Hopkins Outpatient Center, an ambulatory care facility located on the campus of The Johns Hopkins Hospital in Baltimore, patients were engaged as an observer in monitoring hand hygiene compliance. Methods The Johns Hopkins Hospital's ambulatory quality and patient safety (AQPS) task force, after assessing common methods of monitoring hand hygiene compliance including direct observation, self-reporting, and product usage, evaluated using the patient as an observer. Results Of 50 patients interviewed, 43 (86%) indicated a willingness to monitor and report providers' compliance with hand hygiene guidelines. In collaboration with providers, a patient-as-observer hand hygiene monitoring process was developed and piloted. Qualitative feedback postimplementation did not indicate that the process would inhibit the patient-provider relationship. The cost of the program to implement and maintain averages $0.17 per patient encounter. The overall patient response rate was 21.6% (range, 12%–77%), based on completed observation cards to total appointments completed. Hand hygiene compliance as measured by the patient-as-observer process averaged 88% (range, 74%–100%). Independent observation revealed 100% concurrence between the patient's recorded observation and the independent observer. Discussion Engaging the patient to report on hand hygiene compliance was found to be efficient and acceptable to patients and providers, and the results of the observations were representative of actual provider behavior.

IN THE UNITED STATES, an estimated 1 million people are infected with the humanimmunodeficiency virus (HIV) and one-quarter are unaware of their infection. 1 Rates of newinfections have increased among young persons with nearly half of all new HIV infections inthe US occurring in black adolescents and young adults aged 13 to 24.1-4Despite evidence that early diagnosis may have potential advantages in promoting prevention,5-8 improving immune restoration, and linking HIV-infected persons with care9 HIV testinghas been a controversial and difficult area to define and produce relevant guidelines. In 2001,the Centers for Disease Control and Prevention 10 (CDC) recommended universal HIV testingfor all persons who (a) live in communities with an HIV prevalence >1%; (b) have known riskfactors for HIV infection; and (c) request HIV testing. In September 2006, the guidelines forhealth care settings were modified to recommend that all persons aged 13 to 64 years be testedfor HIV.11Understanding risk-based care delivery patterns of providers who care for vulnerablepopulations is salient to understanding the acceptance of the current guidelines. The purposeof this study was to determine if care-seeking adolescents and young adults who were receivingsexually transmitted infection (STI) testing and living in a high-HIV–prevalent communitywere being tested for HIV according to CDC guidelines.To select adolescents who fall in the special CDC risk categories, medical records ofadolescents and young adults aged 11 to 24 years who were evaluated for an STI in a largeacademic ambulatory care facility in Baltimore, MD, between July 2003 and June 2004 werereviewed. This time frame was used to include time points in all seasons. This multidisciplinarypractice provides general pediatric care, adolescent medicine primary and subspecialty care,and HIV primary and specialty care as a 3-team structure. Most of the patients served by thisclinic are from the Baltimore metropolitan area. Baltimore is a large city on the east coast ofthe United States that is 64% black, has 23% of the population living below poverty level,12and an estimated community HIV incidence of 166.8 per 100,000 persons.13 The clinic isprimarily staffed by resident, fellow, and nurse practitioner providers supervised by attendingphysicians. Counselors are also available on-site to provide pre/posttest HIV counseling andgeneral STI/HIV risk reduction counseling to adolescents.Quality assurance (QA) laboratory logs were used to randomly identify patients who had STIand/or HIV testing during the study period. Inclusion criteria for chart review included (a) agebetween 11 and 24 years and (b) evidence of STI screening or testing at the visit during the

Sinusitis is considered one of the most common diseases in childhood, though no actual figures are quoted in the medical literature. This study, which was conducted in an ambulatory care facility a...

The Massachusetts General Hospital developed a series of space and utilization guidelines that assisted in the planning of a 450,000-ft ambulatory care facility. The guidelines attempted to balance and preserve the critical elements of the hospital's culture while, at the same time, create a highly efficient ambulatory care building. This article discusses the economic, political, and cultural implications of implementing specific project principles and guidelines known as the "9 Commandments."

PURPOSE: Efforts to reduce patients' out-of-pocket expenses for prescription drugs by incorporating pharmaceutical manufacturer assistance programs (PMAPs) into a private ambulatory care facility's pharmaceutical services are described. SUMMARY: From March 2001 through March 2002, the clinic's pharmacist prospectively evaluated patients for PMAP enrollment. The pharmacist completed the pharmaceutical manufacturer's application forms for patients identified as candidates for PMAP assistance and helped them obtain documentation. Some companies sent medications directly to patients, and others sent them to the clinic, where they were stored until the patients picked them up. The patients informed the pharmacist when refills were needed, which allowed the pharmacist to review patient records, verify compliance, and ensure proper follow-up. Forty-four patients were enrolled in 22 PMAPs during the year. The mean +/- S.D. annual household income for all patients was 15,631 dollars +/- 7,845 dollars. A total of 115 medication orders were processed for the patients. The mean +/- S.D. number of medications per patient obtained through PMAPs was 2.5 +/- 1.8, and the mean +/- S.D. number of refills was 1.8 +/- 1.0. The total cost of the medications was 48,143 dollars. The pharmacist needed an average of 15-20 minutes to perform the initial patient interview, 10-15 minutes to complete each initial application, and 5-15 minutes to complete a renewal application. Total pharmacist time needed to process each medication order was estimated at about one hour per year. CONCLUSION: A pharmacist in a private ambulatory care facility helped patients enroll in PMAPs and reduced the patients' expenses for prescription drugs.

ISSUE: The 2004 New Jersey Department of Health and Senior Services (NJDHSS) Ambulatory Care Regulations require that each state licensed ambulatory care facility develop and implement an infection control program that is overseen by an infection control professional (ICP) who is certified by the Certification Board of Infection Control. PROJECT: Several experienced, certified ICP's in the northern New Jersey area formed an affiliated consultant group with the goal of providing quality, consistent infection control programs for ambulatory care centers. Services may include initial and periodic worksite inspections, development and/or review of the facility's infection control plan, policies, procedures, recordkeeping, educational programs and phone consultation as needed. Potential clients are matched with ICP's depending on interest and experience in specific ambulatory care services such as surgery, endoscopy, renal services, or radiology. The ambulatory care center and the ICP design a contract specifying the services that meet the client's needs. Worksite inspections and phone consultation or coverage are provided by individual ICP's. Policy manuals and educational programs are developed using the group expertise of several ICP's with experience in the specific service areas. The group is comprised of both fulltime consultants, and ICP's who subcontract on a part-time basis. The affiliated consultants are marketed through professional websites as well as word of mouth. By including several members throughout the state, the group is able to offer services to facilities across a wide geographical area. RESULTS: Using the affiliated approach, to date the group has assisted over forty outpatient facilities in fulfilling state licensure requirements by providing access to infection control programs developed and supported by certified ICP's. For the consultant, the group approach reduces individual costs for resources, legal fees, and operating expenses, and permits flexibility for members to determine the amount of time they wish to devote to consulting. LESSONS LEARNED: As more state and federal regulating and accrediting agencies place greater emphasis on requirements for certified ICP's in various outpatient settings, infection prevention professionals must collaborate to provide standardized infection control programs in an efficient, cost-effective manner.

Most tonsillectomies are performed as outpatient procedures in an ambulatory care facility. The postoperative period can be protracted, which can cause dehydration and readmission to the hospital. Timely intervention with home intravenous (IV) hydration can help prevent this complication. A prospective clinical trial was designed to evaluate the benefit of home IV therapy after tonsillectomy. One hundred consecutive patients underwent tonsillectomy. Fifty returned home without home IV hydration and another 50 returned home with home IV hydration. Clinical data were collected by the homecare nurse during the postoperative period. Comparison between these two groups showed that the patients with home IV hydration had less morbidity. Daily assessment of the patient by telephone is the best screening method to determine the need for IV hydration for the posttonsillectomy patient.

Educational objectives: To develop an exposure control plan for an otolaryngology office or ambulatory care facility and to teach universal precautions, proper use of personal protective equipment, and safe techniques to otolaryngology office employees.

Failed patient appointments in ambulatory care may result in decreased revenues. The purpose of this study was to determine if patient reminders would affect the "no-show" rate of a medical ambulatory care setting. Patients of 10 physicians participated in a 6-week study. Patients were randomly assigned to one of three groups: 2 weeks of appointment reminder postcards, 2 weeks of appointment reminder phone calls, and 2 weeks of no intervention. Chi-square analysis revealed significant differences between the control group and the two groups receiving interventions. Patient reminders may be a mechanism to decrease the no-show rate in ambulatory care.

This article describes how the H. Claude Hudson Comprehensive Health Center (Los Angeles) implemented a continuous quality improvement program to reduce the unacceptably high rate of nonrepresentative Papanicolaou (Pap) smears (those lacking endocervical component). A review of the literature and telephone surveys indicated that the optimal Pap smear technique includes the use of a cervical cytobrush. Several cytobrushes were evaluated and one was chosen to be used facilitywide. Clinicians were given in-services on the proper cervical sampling techniques using the cytobrush. The rate of nonrepresentative Pap smears decreased approximately 12% during a five-month period; this has been attributed to uniform implementation of the cytobrush technique in nonpregnant patients, in-service education, and cooperative teamwork.

Objectives: To increase pediatric residents' knowledge of the Guidelines for the Diagnosis and Management of Asthma (GDMA) developed by the Expert Panel of the National Asthma Education Program and to increase the residents' confidence in their ability to implement these guidelines. Emphasis was placed on the diagnosis and treatment of Hispanic children with asthma, a population at increased risk for morbidity. Setting: A continuity care clinic located in an urban ambulatory care facility. Subjects: Forty-four pediatric residents: 17 first-year residents, 15 second-year residents,and 12 third-year residents. Methods: Residents participated in a multicomponent asthma management curriculum that stressed active learning strategies, including the following: focus groups, computer-based testing, lectures, hands-on skill development seminars, role modeling by attending pediatricians, provision of GDMA pocket cards and posters, access to peak flowmeters and spirometry, and an interactive computer-based module. Content focused on pulmonary function testing with spirometry and peak flowmeters, stepwise use of medications, recognition of asthma symptoms and triggers, and cultural considerations that impact asthma management. Pediatric faculty and fellows also participated in a series of asthma seminars to increase the likelihood that faculty would role model the GDMA and provide appropriate feedback to residents. Results: Pediatric residents demonstrated significant increases in knowledge about evaluation of asthma, pulmonary function testing, and clinical management, displayed significantly enhanced levels of confidence, and were enthusiastic about the asthma management curriculum, rating it significantly higher than 15 other content areas in the general pediatric curriculum. (Arch Pediatr Adolesc Med. 1994;148:595-601)

Physicians are a largely untapped resource for evaluating medical care delivery in an ambulatory care facility. This study includes the attitudes of physicians in assessing care at the Northwestern University Medical School Clinics (NUMSC). A self-administered questionnaire was mailed to all clinic chiefs, attending physicians, and resident physicians who had worked in the clinics during the summer of 1973. Using a similar questionnaire, personal interviews were conducted with a sample of patients in the clinics. Physicians were consistently more critical than patients in their responses to the battery of questions on satisfaction and on indices constructed from these responses. The findings indicate a negative relationship between the physician's position of authority in the organization and his report of satisfaction: clinic chiefs were consistently more critical than either attending physicians or resident physicians, while the comparisons between attendings and residents were more mixed. Further, salaried physicians were more critical than those who received no salary and non-AMA members were more critical than AMA members. Adding the assessment of physicians to those of patients introduces a useful complement and strengthens the utility of such evaluation instruments.

This chapter is an overview of the management of a patient who has undergone a surgical procedure in an outpatient setting. It addresses the complications that are most common in this setting and their management. Without attempting a thorough discussion of every conceivable complication, this discussion seeks nonetheless to be reasonably comprehensive. Perhaps the most straightforward means of presenting this information is to follow chronologically the patient's experience from the moment the procedure has been concluded, through his recovery room care, and finally look at the patient's needs and experiences after leaving the ambulatory care facility.

The literature is replete with documentation of nurse practitioner function, including its effectiveness, safety, and client acceptance(l). Little information, though, is available about drug prescribing patterns by nurses, as the responsibility for prescribing drugs is almost exclusively held by the medical and dental professions. The recent report of the Graduate Medical Education National Advisory Committee (GMENAC) recommends that limited prescribing responsibility be granted to other professions, including nurses(2). Several states have enacted legislation permitting nurses to prescribe drugs. Michigan, for one, permits nurses to prescribe drugs with physician supervision (3,4). The clinical nurse specialists of the Primary Care Nursing Service (PCNS) of Detroit Receiving Hospital/University Health Center (DRH/UHC), an urban universityaffiliated ambulatory care facility, is one group of nurses who do prescribe drugs with physician supervision. The PCNS is staffed by six clinical nurse specialists (CNS) who offer primary nursing care to adults and adolescents. The primary care to clients is distinctive, as it is consistent with nursing philosophy and reconciles the philosophy to function(5). The approach to client management is health oriented and prevention centered and emphasizes care of the whole person. Each of these elements is integral to the nursing framework here and comprises the approach to care. Many clients use the PCNS as their entry point into the health care system. An ongoing relationship develops between client and nurse. The nurse assumes responsibility for coordination of additional health and medical care needs of the client through consultation with and referral to other health professionals. Physician consultation is available on site, which provides the legal and operational mechanism for prescribing drugs. The nurses are prepared at the master's degree level in nursing and are certified as nurse practitioners by the American Nurses' Association. All are adjunct assistant professors at the College of Nursing at Wayne State University. Sixty percent of their time is spent in clinical practice, with the remaining time centered on student education, both in the classroom and clinical area. All the nurses have had considerable direct client care experience, ranging from 9 to 17 years. Each nurse has had a basic pharmacology course in her undergraduate nursing curriculum. At the graduate level, each had additional classroom and clinical experience in DO()NNA Mt\NR()E. N(:, CSN. is assistant professor of nursing, University of Southern California, Dept. of Nursing, Los Angeles.

In a Veterans Administration ambulatory care facility staffed by experienced nurse practitioners, we observed the length of visits, time utilization for various activities, and the use of diagnostic tests before and after introducing algorithms for 12 common chief complaints. Charges for diagnostic tests decreased as much as 40 per cent, primarily because of reduced utilization of radiographs such as spine films. Nurse practitioner productivity was unaffected once the nurse practitioners became familiar with the algorithms. Outcome of illness did not change measurably, but the process of care improved as reflected by more complete data collection documented in the medical record.

The author describes the process used to develop a patient classification system in a large multi-specialty ambulatory care facility. The process involved identifying critical indicators for each specialty area, validating the instruments, and calculating the workload. The approach to sampling and the problems encountered for relatively short visits are discussed.

Made available in DSpace on 2018-11-26T15:45:41Z (GMT). No. of bitstreams: 0 Previous issue date: 2017-09-01. Added 1 bitstream(s) on 2019-10-09T18:25:18Z : No. of bitstreams: 1 S0037-86822017000500607.pdf: 774150 bytes, checksum: 47f2bc87c52631307d7f212ae936aefa (MD5) Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) Introduction: In the 1990s, Brazil adopted a public policy that allowed for universal, free access to antiretroviral therapy (ART). Since then, treatment adherence has become a new challenge for administrators of sexually transmitted disease/acquired immunodeficiency syndrome (STD/AIDS) policies. This study quantified adherence to ART and verified whether there is an association between sociodemographic variables and clinical/laboratory data in human immunodeficiency virus (HIV)-infected patients. Methods: This was a cross-sectional, exploratory study with a quantitative approach that was conducted over 8 months. The target population contained patients who were assisted at the ambulatory care facility specialized in STD/AIDS of a medium-size city located in Northwest Sao Paulo. In order to verify the level of adherence to ART, a validated CEAT-VIH (Assessment of Adherence to Antiretroviral Therapy Questionnaire) questionnaire was used. Sociodemographic aspects and clinical/laboratory data were obtained from the medical records. The results were analyzed using the Student's t-test and Pearson's coefficient. Results: Herein, 109 patients were interviewed, 56% of whom were male. The age of the population ranged 18-74 years (mean 45.67 years). Adherence to ART was classified as insufficient in 80.7% of cases. There was an association between ART adherence and presence of symptoms and/or opportunistic infection (p=0.008) and economic status (p

The use of implantable vascular access devices has increased rapidly in recent years. We have placed the new Implantofix Implantable Drug Delivery System 7500 in 19 patients. The patients reported only minor discomfort. The majority of the nurses found the Implantofix port easier to access than other ports, and some reported less swelling and soreness at the port site. Some of the physicians had difficulty visualizing the radiopaque catheter on X-ray; Burron is currently developing a more radiopaque system. The Implantofix system offers several important benefits. Its compact size assures minimal discomfort for the patient. A new peel-away sheath offers a choice of insertion methods. The system is particularly economical because it can be implanted in an ambulatory care facility or an outpatient surgery room equipped with fluoroscopic capabilities.

The delivery of health care had emerged as one of the most important political issues of the 1970's, yet public attitudes about health issues remains a relatively unexplored subject. Little is known about the public's opinion of who should control the delivery of health care, about how the costs of health care are perceived, or about how the delivery of care should be financed. This paper relates respondent attitudes on these subjects to attitudes about criteria that determine the respondent's choice of ambulatory care facility and to socioeconomic, political, and other demographic characteristics. The data are derived from a survey (N=521) of households representative of the area of Rochester, New York.

The trend in cancer care today is to successfully maintain the patient outside the traditional inpatient setting. This review has focused on some of the advantages and disadvantages in the administration of chemotherapy at home, the physician's office, and the ambulatory care facility. Effective planning for chemotherapy administration and the selection process for each of these settings depends on the needs of the patient and family. We can conclude that, although it is possible to use a combination of setting to maximize patient care, the ambulatory care concept provides broader choices for patients, families, and clinicians.

Utilization of emergency departments in Rochester, NY, has increased dramatically in recent years. A sample of the community's emergency department cases were classified as to whether care could have been given in an emergency department, physician's office, or could have been delayed. Only 35% of the cases were classified as needing care in an emergency department. The rate of emergency department utilization for low socioeconomic areas was six times that of high socioeconomic areas. Analysis of a community's emergency department utilization provides data for planning ambulatory services. The emergency department is only one element in the community ambulatory health system. Part of the emergency department demand may be more appropriately met in another type of ambulatory care facility.